Diabetes mellitus (DM) affects more than 382 million people around the world, of whom 90% are diagnosed with type-2 DM (T2DM) [1]. The prevalence of T2DM has increased dramatically during the last 2 decades. The Arab world is not immune from this epidemic in the prevalence of T2DM. In fact, the Middle Eastern and North African region has the second highest rate of increase in diabetes globally, with the number of people with diabetes is projected to increase by 96.2% in 2035 [1,2].

The burden of DMT2, obesity, and cardiovascular disease is particularly high in Arabic countries. Obesity, physical inactivity, and excessive intake of nutrient-poor, calorie-rich foods are among the many factors contributing to this increased prevalence [3]. Indeed, the high risk of both diabetes and cardiovascular disease associated with obesity in Arabs may be due to a predisposition to abdominal obesity which can lead to the metabolic syndrome. According to the available data in the Arab world, overweight and obesity are prevalent even in poorer countries, as well as in low-income groups within these countries, exacerbating the burden on health authorities in the prevention and control of these diseases [4-9].

The silver lining is that, prevent or delay diabetes epidemic is possible. However, the impact and implementation of any prevention programme face a big challenge in ground. Therefore, this editorial sheds the light on central domain in any prevention program, namely cultural context, with consideration to Arabic community.

Globally, the prevalence of chronic, non-communicable diseases is increasing at an alarming rate. New figures by the International Diabetes Federation (IDF) indicate that the number of people living with diabetes is expected to rise worldwide from
366 million in 2011 to 552 million by 2030. Also, 80% of people
with diabetes live in low and middle income countries. In the Middle East and North Africa Region, 32.6 million or 9.1% of the population now have diabetes and this number is expected to double in less than 20 years. IDF anticipates that by 2030, 11% of the Middle East and North Africa region or 59.7 million people will be living with diabetes; six out of the world’s top ten countries [10]. WHO predicts that developing countries will bear the brunt of this epidemic in the 21st century [11].

In 1985 there were an estimated 30 million people with diabetes. Today diabetes affects more than 366 million people of the world’s adult population [10]. With improvement in economic situation in developing countries, increasing prevalence of obesity and the metabolic syndrome is seen in adults and particularly in children. The main causes are increasing urbanization, nutrition transition, and reduced physical activity. Furthermore, aggressive community nutrition intervention programs for undernourished children may increase obesity. Some evidence suggests that widely prevalent perinatal under nutrition and childhood catch-up obesity may play a role in adult-onset metabolic syndrome and DMT2 [12].

Dagogo-Jack [13] reported that by the year 2025, more than three-quarters of all persons with diabetes will reside in developing countries [13]. One may recommend that an aggressive diabetes prevention programme (DPP) is urgently needed in order to stop this pandemic. Such programme should take into consideration an important domain in any public health prevention programme, namely the lifestyle changes. Indeed, addressing any lifestyle changes in Arabic countries require deep understanding for their culture and lifestyle.

According to the Social Science Encyclopedia, culture is defined as the way people live their lives [14]. It consists of conventional patterns of thought and behaviour, including values, beliefs and rules of conduct, which are passed from one generation to the next by learning and not by biological inheritance. For instance, what we eat or drink and what we
believe depend largely upon our culture. As mentioned above
that recent scientific evidence supports that the notion of
diabetes prevention through lifestyle changes, addressing
lifestyle changes in certain country or community need to take
the cultural context into account from general and specific
perspective.

The growing prevalence of type 2 diabetes and cardiovascular
disease is tied to excess weight. In the past 20 years, the rates
of obesity have tripled in developing countries that have been
adopting a western lifestyle involving decreased physical activity
and overconsumption of cheap, energy-dense food. Populationbased
surveys of 75 communities in 32 countries show that
diabetes is rare in communities in developing countries where a
traditional lifestyle has been preserved. By contrast, some Arab,
migrant Asian Indian, Chinese, and U.S. Hispanic communities
that have undergone westernization and urbanization are at
higher risk; in these populations, the prevalence of diabetes
ranges from 14 to 20%. In addition, most of the population
growth in the developing world is taking place in urban areas
[15].

As DMT2 is a disorder resulting from changes in lifestyle,
one has to admit that there is a great need for health workers
to be aware and sensitive to the cultural dimension and its
significance in the care giving process [16]. The key issue after
understanding the lifestyle of people is to help them change it
toward healthy lifestyle. However, changing human behaviour is
a complex clinical competency of the 21st century.

The literature on health behaviour change is usually specific
to a given culture/community. Thus, this study will shed the light
on one particular culture in developing countries, namely Arabic
culture, and the pros and cons of cultural habits. Also, suggest
some recommendations for the target population in order to
prevent the widespread of diabetes.

The term Arab is associated with a particular region of the
world. Almost all of the people in the region extending from
the Atlantic coast of Northern Africa to the Arabian Gulf. The
classification is based largely on common language (Arabic) and
a shared sense of geographic, historical, and cultural identity.
The term Arab is not a racial classification, but includes peoples
with widely varied physical features. Actually, there are 10 Arab
countries in Africa (Morocco, Mauritania, Algeria, Tunisia, Libya,
Sudan, Somalia, Eritrea, Djibouti and Egypt) and 12 countries in
Asia (Iraq, Jordan, Lebanon, Syria, Kuwait, Bahrain, Qatar, Oman,
United Arab Emirates, Saudi Arabia, Yemen, and the people of
Palestine. Palestinians are presently either living under Israeli
rule, autonomy of partial Palestinian Authority, or dispersed
throughout the world. Despite the national boundaries drawn between the Arabs in the post-colonial period, the Arabs on
the popular level view themselves as a unified entity. Arabs are
not homogeneous with respect to religious belief, but include
Christians, Jews, and Muslims. The large majority of Arabs are
Muslim (92%). The religion of Islam is closely associated with
Arab identity because of the origin of Islam in the Arabian
Peninsula and the fact that the language of Arabic is the sacred
language of the Holy Koran.

The followers of Islam were founded in the seventh century
by Prophet Mohammed in the Arabian Peninsula. The literal
meaning of Islam means total submission to Allah. Muslims
believe that the Islamic teachings should control every aspect of
their life, whether great or small. Thus, understanding Muslims
“correct” and “not correct” behaviour/lifestyle with related to
social environment and diabetes prevention and intervention is
the spine of a given editorial.

Although elements of free exist in Islam, Muslim society
emphasis on fatalism as a result of repressive political and
economic systems that have rendered people powerless. Fatalism
the beliefs that events are controlled and predetermined by
God “Allah” and that human have little, if any, control over their
destinies is a psychological mechanism that reconciles people
with their harsh reality and justifies their inability to control
and shape their destinies. In diabetes, would be that they are
unable to influence their disease in any way [17]. Indeed, Islamic
society and its culture are based on the precise teachings of the
Koran and the Sunna. Fatalism is a complex phenomenon; one
may argue in this article that religious sentiments, including
those that attribute a positive value to steadfastness in suffering,
should not be seen as passive, as anti-science, or as constraints to
medical treatment. In various ways, Muslims grappled with how
to achieve the most benefit for themselves and their families while
trying to conform to what would please God. Reliance on God,
as an Islamic essence, should not be understood in opposition
to seeking treatment or prevention, we should not ask whether
patients appeal to God or seek treatment or strategic way for
prevention, for one does not necessarily exclude the other. There
is a social environment and social support to remain attentive to
the interrelations between the two.

Fatalism in diabetes is not well documented; we still do not
know much whether the perspective of fatalism is applicable
among minority populations in different geographical location,
and whether it is associated with different socioeconomic status.
Given editorial highlights on two aspects of Muslims lifestyle
and daily living activities and strongly related to diabetes and
its development. The first one is related to an important domain
of people lifestyle, namely diet. The second example is related
to physical activity. These two domains are vital to any diabetes
prevention or cure programme aim to be implemented in
practice.

Firstly, Hospitality and Generosity as Islam’s Essence: exceed
the limits and avoid diet. Arab Middle Eastern society can be
characterized by intense and intricate rituals in which food
fulfils important social functions. The host serves the guest food
as a sign of hospitality and as a demonstration of honour to the
guest. The guest accepts the food as a gesture of friendship, a
sign of respect to the host, and as an affirmation of the host’s
prestige. Not only do hosts’ offer foods unrestricted in variety,
quantity and quality, but it is also customary to coerce the
guests into eating above and beyond what they are capable of. In
addition, The Arab hold negative views about slim or thin bodies
in the case of both females and males, except in affluent sectors
where the slender body type is preferred. For Arabs and many
Africans, weight gain or plumpness is socially desired as a sign
of beauty for women, and a sign of affluence and wealth for men
[18]. Slim people are thought of as having tuberculosis, AIDS or
cancer [19]. Thus, one does wonder where such believe among
people comes from and whether Muslim Arabs, for instance,
knowledgeable about healthy lifestyle. The Intrinsic complex
phenomena seem to be hierarchy in which or what is accepted to
be healthy (small portion size, limited rich and fatty food) rather
than lack of knowledge. The social environment for Muslims
supports the notion of modesty. For example, God say in Koran: “Eat and drink and be not immoderate” (Koran 7:31) [20]. Allah
also says: “O you who believe, do not forbid the good things
which Allah has made lawful for you and do not exceed limits.
Surely Allah does not love those who exceed the limits” (Koran
5:90) [21]. One may suggest that such statements from Koran
have a very positive meaning to toward well-being, thus, there
is a need for a comprehensive approach address such Islamic
statements and put it in action.

Secondly, physical activity as a central point for health
and well-being: being Overweight as a measure of Prestige
and Wealth status. In harsh contrast to Western culture, being
overweight in the Middle East is historically associated with
high social status. In actual fact, Overall fatness is associated
with strength and wealth. People at risk of DMT2 or those have
diabetes, therefore, may not be at all motivated to lose weight.
In addition, weight loss is not desirable because it raises the
suspicion that the person has a serious illness or has diabetes, as
mentioned above. Even though the preference for body shape is
gradually moving from fatness to thinness because of increased
exposure to Western values through the media, this shift is
taking place amongst the youth and is not necessarily affecting
the population with type 2 diabetes which mainly consists of
people over 40 due to IDF. Culturally, exercise and sports are
viewed by some people as activities for young people [22]. Older
people are excluded from exercise by the virtue of their senior
status [23]. One may argue that there is an urgent need to shift
toward the approach of exercise for young and old people in
Arab-Muslim countries.

Islam social environment emphasis on not only a moderate
and simple diet, as mentioned in the first example, but also on physical exercise/activity. For instance, the daily prayer is
itself a form of exercise, as its prescribed movements involve all
muscles and joints of the body, 5 times a day, as well as providing
a way of meditation and relieving mental stress, this ultimately
leads to Discipline. In fact, Living with diabetes or being at high
risk of diabetes requires a lot of self-discipline in terms of careful
attention to diet, rigorous timing of self-medication, frequent
testing of blood sugar, sticking to an exercise regime and others

Creating declaration on an Islamic perspective on
diabetes similar to Amman/Jordan Declaration on an Islamic
Perspective on Health supported and published by the World
Health Organization, such declaration can be a resource for
the health care practitioner and patient to guide healthy
living practices in Arabic countries [24,25].

Health professionals need to assess an individual’s
motivation and willingness to stick to recommendations; the
healthcare professional’s may ask the person with diabetes
to help develop his or her own plan of action to eliminate
the secondary and tertiary complications. Perceived barriers
towards the implementation of self-management can then
be discussed, taking into consideration the daily lifestyle as
well as the social environment.

DPP should translate “gold standard” programme
to “real world” health care settings by identifying factors
that may be barriers to the individual to implement each
behavioural change as well as facilitators based on the
environmental factors for individual persons, city, and
country.

Raise the importance of family education and awareness
in order shift habits and support in the prevention of diabetes
(for example, the individual goal of healthy eating compared
with the shame to the family of not providing guests with
generous “special menu” food).

Religious teachings (Mosque, university and school)
can be used to effect behaviour change based on verses from
the Koran and Haddith, i.e. the examples of Koran used above,
which supporting healthy lifestyle practices (e.g., guidance
with respect to eating in moderation, being physically active,
not smoking).

Run and organise public health workshop from Islamic
perspective in order to increase the awareness of the Islamic
perspective in diabetes at prevention and management level.
Such workshops need to give practical examples for people
form their own daily life and advise them to the right way.

“Educated” Muslim women are seen as better able to
resist social pressure and make up their own minds about
taking exercise. [26] Suggests that critical health literacy
may be a prerequisite for the goal of empowerment in Arab-
Muslim’s society facing diabetes epidemic.

Health application, Smart phones represent 40% of total
impressions in the Middle East, which is 45% higher than the
global average, according to a report by In Mobi. Smartphone
penetration in the Middle East region is projected to grow up
to 39% by 2015. [27-30] therefore, e Health applications can
be useful for any lifestyle changes toward being physically
active and use the mobile applications to perform active
lifestyle.

To Sum up, the prevalence of diabetes has reached epidemic
proportions. The 21st century is hallmarked by lifestyle
conditions which are associated with substantial social and
economic burdens in developing countries, which contains
several ethnic and religious groups. Arab-Muslims are, by far, one
of the large population groups for Middle Eastern and African
nations. Understanding their culture is crucial for any practical
prevention or intervention programme, due to its relationship to
bad and good behaviour, which with time may lead to diabetes
and/or worsen its complications. We suggest understanding
and differentiating which or what is accepted to be healthy in
“Arab-Muslims society” and which or what is healthy in “reality”.
Also, screening studies considering lifestyle, level of physical
actives, diet and environmental factors as well as culturally
sensitive community-based strategies aimed at prevention
and management of obesity and its metabolic complications
would be crucial for any effective action. Furthermore, Islamic
statements which enhance well-being and healthy lifestyle are
urgently needed in order to shift the paradigm. Individual’s
misunderstanding for number of Islamic essences, i.e. Hospitality
and Generosity, could be translated to cultural habits influencing
people life and bring them many metabolic disorders such as
diabetes. Therefore, an enormous effort among local countries
is urgently needed in order to implement effective programmes
and put it in action, mainly in areas where the level of education
and health policy is at low level.